Sisyphus' Alert: The Uphill Struggle to Improve Venous Thromboembolism Prophylaxis Clinical Decision Support

Chemoprophylaxis reduces the risk of hospital-acquired venous thromboembolism (VTE), but is not reliably ordered. Our institution created a clinical decision support (CDS) interruptive alert to remind clinicians to order VTE chemoprophylaxis when it is missing for qualifying inpatients. Unfortunately, this alert has required repeated modifications to ensure accurate logic, and continues to generate negative feedback from users.This study aimed to describe multiple failures in the development and postdeployment optimization of this interruptive alert, and our lessons learned.This study analyzed the number of times this alert fired over 6 months of testing and 16 months of deployment, and changes in either the frequency of alert firing or the frequency of the alert being dismissed without orders placed with iterative changes in the alert logic. Feedback about this alert was compiled and classified into common themes.The initial alert fired an average of 11,154 times per week when tested silently, prompting significant refinements before release. The alert shown to users fired an average of 53.8 times per 1,000 patient days in the first 6 months of the study period. Despite postlaunch improvements, this rose to 61 alerts per 1,000 patient days in the final 6 months of the study. Modifications also did not cause a significant decrease in how frequently the alert was dismissed without further action being taken (88%). Review of narrative feedback and its classification highlights "wrong person" receiving the alert being by far the most prevalent cause for negative submitted user feedback (nearly 50%), despite efforts to develop logic that limits firing to the patient's primary team.Changes to this VTE alert were summarized as failures to meet the "five rights" of CDS. Alerts for high-priority safety issues require persistent feedback-driven improvement, particularly when there is poor performance or negative user experience.